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INTRODUCTION

The most common time of onset for psychotic disorders is adolescence and early adulthood []. The onset of psychotic disorders is usually preceded by a prodromal period characterized by non-specific psychiatric and attenuated psychotic symptoms accompanied by functional decline []. "Ultra-high risk" (UHR) for psychosis is defined by the presence of attenuated positive psychotic symptoms without full impairment of reality testing. Recently, the UHR concept was included in "attenuated psychosis syndrome" (APS), a new diagnosis contained in Section 3 of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the section reserved for conditions requiring further research []. Among adolescents who reported psychotic-like experiences, those of 80% remitted, and the symptoms of 20% persisted []. The early detection and treatment of people at risk for psychosis is currently regarded as a promising strategy for preventing the devastating consequences of full-blown psychosis [].

As children and adolescents spend a large portion of their time at school, mental health problems are commonly identified in this setting. School-based detection of those at UHR for psychosis has the benefit of improving access to mental health treatment for students who have psychotic-like experiences. In Korea, mandatory school based mental health screening test for mental health problems of students has been conducted every year. Due to limited school mental health resources, school counselors perform non-counseling related activities beyond their training such as clinical expertise regarding to assessment and referral of clinical high risk students.

Given increasing recognition of the need to identify individuals with UHR risk status, school counselors are facing the challenge of how to understand and deal with these symptoms. Indeed, in view of the essential contribution of the identification of symptoms to the provision of effective mental health services, it is essential to recognize the potential role played by school counselors.

Thus, the current study examined how school counselors diagnose and define the appropriate treatment for those at UHR for psychosis. We assessed respondents' recognition of UHR for psychosis based their responses to a brief vignette depicting a hypothetical student reporting relevant symptoms.

METHODS

Participants

The sample for this anonymous cross-sectional survey, which was conducted in October 2015, consisted of school counselors. In total, 132 school counselors from 125 (81.7%) of the 153 schools and all of three Wee centers in Gwangju metropolitan city participated in the survey and completed the questionnaire. Data on sociodemographic characteristics were collected. The survey was approved by the the Chonnam National University Hospital Institutional Review Board (CNUH-2015-171).

Vignette

The vignette used in this study was developed by the corresponding author (KSW) () based on the vignette developed by Jacobs et al. [] and the manual of Personal Assessment and Crisis Evaluation (PACE) clinic of Orygen Youth Health in Melbourne, Australia []. The vignette described a fictional individual at UHR for psychosis according to the Comprehensive Assessment of At-Risk Mental States (CAARMS) criteria [,]. The protagonist in the vignette met criteria for subthreshold non-bizarre ideation and perceptual abnormality with functional decline. She also met criteria of the DSM-5 criteria for APS. Two authors (LJY and CYC) with extensive experience in this area discussed and further revised the vignette.

First, we asked participants whether the vignette depicted a psychiatric disorder (yes/no/don't know). Participants were asked to identify the most appropriate diagnosis for the hypothetical student from a list of 10 diagnoses. We also asked participants to recommend an appropriate referral and treatment approach for the student by asking them to rate 11 treatment options on the following scale: first choice, second-or-later choice, would not recommend, and no opinion. Participants who diagnosed the protagonist with schizophrenia, delusional disorder, or at UHR for psychosis were considered the "schizophrenia spectrum disorders group," and others were considered the "non-psychotic disorders group."

Statistical analyses

Basic demographic differences among respondents according to the diagnosis chosen were analyzed using the chi-square test. The percentage of respondents choosing each answer was calculated and is presented. SPSS for Windows software (ver. 21.0; IBM Corp., Armonk, NY, USA) was used to perform the statistical tests. All statistical tests were two-tailed, and p-values <0.05 were deemed to indicate statistical significance.

RESULTS

Demographic characteristics of participants

The sample consisted primarily of females (94.7%), and there were no significant differences in the demographic characteristics of respondents according to the diagnosis they selected ().

Diagnosis

In total, 123 (94.6%) respondents recognized that the vignette depicted someone with a mental disorder. The data regarding diagnoses are summarized in , which shows the percentage of respondents choosing each diagnosis. The most common diagnosis was schizophrenia (n=34, 28.1%), followed by delusional disorder (n=32, 26.4%), and depressive disorder (n=23, 19.0%). The diagnosis of UHR for psychosis was selected by 15 (12.4%) subjects.

Referral and treatment

shows the referral recommendations according to the diagnosis chosen by the school counselors. Most participants who diagnosed the protagonist with schizophrenia spectrum disorder selected psychiatric clinics as the optimal referral. Additionally, an average of 58.1% of respondents would refer to Wee center, which is school counseling services, and an average of 37.2% would refer to a private counseling center.

shows treatment preferences according to the diagnosis chosen by school counselors. School counselors who diagnosed the student depicted in the vignette with schizophrenia were likely to recommend antipsychotics (35.3%) and family therapy (35.3%) as the first-line treatment. School counselors who diagnosed the protagonist as being at UHR for psychosis were also likely to prefer family therapy (46.7%). In terms of the medication options for those at UHR for psychosis, antipsychotics were the most frequently chosen.

DISCUSSION

This is the first study to explore the recognition of Korean school counselors regarding students at UHR for psychosis. Participants were presented with a vignette depicting the case of a student who initially presents with recent-onset subsyndromal psychotic symptoms with functional decline. We found that most participants believed that the student was suffering from a psychiatric disorder. However, only 12.4% of the respondents correctly diagnosed her as at UHR for psychosis, whereas over half of respondents described her as suffering from a full-blown psychotic disorder. This reflects the fact that school counselors may be unfamiliar with the concept of high risk for psychosis, and lack confidence in treating this concept as a potential precursor of psychotic symptoms.

About 40% of school counselors did not consider the protagonist in the vignette to be suffering from schizophrenia spectrum disorder but, instead, believed she was dealing with a less severe condition, including depressive disorder (19.0%). Although the vignette did not portray severe depression, many school counselors nonetheless identified the problem in question as depressive disorder, which is a common psychiatric disorder among students. While most school counselors recommended psychiatric treatment for the protagonist in the vignette, a majority also considered a counseling center, which might not offer psychiatric services and might not operate according to the medical model, as would be appropriate for the treatment of a psychotic disorder. Early detection and intervention have an important role in reducing the duration of untreated psychosis (DUP) and ameliorating the presenting symptoms of UHR subjects [,]. However, appropriate psychiatric intervention is commonly delayed within mental health services, including school counseling systems [,]. Therefore, early referral and the timely delivery of transfer information by school counselors may play an important role in improving the diagnostic and treatment approach of subsequent practitioners.

Our findings reflected great variability in the treatment recommendations offered for the protagonist of the vignette. In particular, school counselors who diagnosed her with schizophrenia or at UHR for psychosis recommended both antipsychotics and family therapy. These results may be attributable to recognition on the part of school counselors that antipsychotics have been established as a standard treatment for persons with psychotic symptoms. Additionally, as school counselors are more frequently exposed to information related to familial and environmental problems, they may consider family therapy to be an important resource for treatment. Although low doses of antipsychotics appear to be effective for reducing the severity of the presenting symptoms of UHR subjects, premature recommendations for medication by school counselors may exacerbate a student's experience of being odd and stigmatized, especially if they are adolescents []. Furthermore, there is growing evidence that psychological interventions, such as cognitive-behavioral therapy, and newly emerging treatments, such as omega-3 fatty acids, may be effective in reducing the severity of the symptoms experienced by individuals at UHR for psychosis [⁻]. These results suggest that Korean school counselors were not familiar with preventive approaches to the development of psychotic disorders or with the importance of early intervention. Thus, we should develop educational materials to raise the awareness of school-based gatekeepers of access to mental health treatment regarding psychosis prevention and help school counselors expand their knowledge about treatment options for those at UHR.

This study has several limitations. First, the use of only one vignette to assess school counselors' recognition of UHR for psychosis may have led to difficulties in distinguishing this condition from other psychotic disorders. Second, we asked only two categorical questions regarding the diagnosis of, and treatment for, individuals at UHR for psychosis; that is, we did not assess such additional factors as respondents' experiences with, goals for, and opinions regarding treatment. Future research may benefit from adding vignettes that depict different levels of psychotic symptoms and elicit more information from respondents. Moreover, as there is no "golden standard" treatment for UHR, the range of recommended treatments in our study should be tested for relevance in futures.

In conclusion, this study suggests that Korean school counselors are not sufficiently familiar with the condition known as UHR for psychosis, although they generally recognize the vignette has mental health problems and needs help. To prevent delays in the implementation of appropriate school-based interventions for attenuated psychotic symptoms, school counselors should be provided with proper education and training.

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School Counselors' Recognition of the Ultra-High Risk for Psychosis

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The most common time of onset for psychotic disorders is adolescence and early adulthood []. The onset of psychotic disorders is usually preceded by a prodromal period characterized by non-specific psychiatric and attenuated psychotic symptoms accompanied by functional decline [].

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Childhood schizophrenia - Symptoms and causes

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This severe mental disorder in children involves hallucinations, delusions, and disordered thinking and behavior that can impair the ability to function.

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El Paso Independent School District Resources and Referrals

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El Paso Independent School District Resources and Referrals

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School Counselor Referral Process examples 

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School Counselor Referral Process examples 

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Missouri comprehensive school counselor referral process guide

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DuPaul, G.J., Weyandt, L.L., Janusis, G.M. (2011). ADHD in the classroom:Effective intervention strategies. Theory into Practice, 50(1), 35-42. http://dx.doi.org/10.1080/00405841.2011.534935

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DuPaul, G.J., Weyandt, L.L., Janusis, G.M. (2011). ADHD in the classroom:Effective intervention strategies. Theory into Practice, 50(1), 35-42. http://dx.doi.org/10.1080/00405841.2011.534935

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ADHD in the classroom; effective intervention strategies

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Lo sentimos, la página que usted busca no se ha podido encontrar. Puede intentar su búsqueda de nuevo o visitar la lista de temas populares.

Children who have obsessive-compulsive disorder (OCD) are plagued with unwanted thoughts, images or impulses that are difficult to suppress, causing them great stress and worry. These are called obsessions. To alleviate the anxiety caused by their obsessive thoughts, they perform repetitive, ritualized actions called compulsions. A child with OCD might need to line things up, touch things in a certain order when leaving the room or wash his hands repeatedly.

Obsessions Common in Kids With OCD

Contamination: Kids with this obsession are sometimes called "germaphobes." In schools, this plays out with kids worrying about other kids sneezing and coughing, touching things that might be dirty or getting sick in many different ways. This is the most common obsession seen in children.

Magical thinking: This is a kind of superstition, like "step on a crack, break your mother's back," taken to extremes. For example, kids might worry that their thoughts can cause someone to get hurt, or get sick. A child might think, "Unless my things are lined up in a certain way, mom will get in a car accident."

Catastrophizing: Some kids easily jump to the conclusion that something terrible has happened. For example, if her parents are five minutes late picking her up, a girl who is catastrophizing might tell herself that they've decided to abandon her.

Scrupulosity: This is when kids have obsessive worries about offending God or being blasphemous in some way.

What ifs: Kids may be plagued by a lot of different kinds of thoughts about bad things they could do. "What if I hurt someone? What if I stab someone? What if I kill someone?"

The "just right feeling": When OCD first develops, from about 6 to 9 years of age, kids may not know why they are doing something, but just that they need to do it until they get what we call the "just right feeling." So: "I'll line these things up until it just kind of feels right, and then I'll stop." And then over time - in the 9- to 12-year-old range - it evolves into magical thinking and becomes more superstitious in nature.

Behaviors You Might See in Students With OCD

Frequent requests to go to the bathroom: This could be to wash hands, if someone near the child was coughing or sneezing, or if she touched something that she perceives as contaminated. She could be washing items-pens, pencils, backpacks, books. It could also be an excuse to get out the classroom and just be away from everyone, and have some respite.

Constant reassurance-seeking: This takes the form of repetitive questions. "Are you sure that's the answer? Could you tell me again? Did you hear what I said?" Checking doors, windows, lockers, desks. Over and over and over again.

Getting stuck on tasks: Sometimes kids with OCD will need to finish something to completion, or understand it to completion, before they're able to move on. So if a child is working out what he did wrong on a math test, and the teacher says, "Now let's open the textbook and start a new chapter," he's not going to be able to shift gears.

Retracing: If a child leaves the classroom and worries that she left a pencil behind, she'll go back into the classroom and go to her desk and check. If she had a bad thought as she went through the doorway, she might have to "fix it" by going back through the doorway again saying a good word. If she had a bad thought when she went down a flight of stairs on the way to class, she might need to go back up that same stairway at the end of the period, even if it means being late to her next class.

Obsessive erasing: A child could be erasing a lot because the letters have to look perfect. Or he could have used a word that disturbs him. For example, if he has a fear of vomiting and he's written the word vomit, he might not be able to stand seeing that word, so he erases it. Kids start having erasers worn down to the metal. Teachers start to see holes in the paper. Words will be drawn over on the back of the page. A lot of different areas of writing become problematic.

Behaviors Often Confused With Another Disorder

Some behaviors associated with OCD are easy to confuse with ADHD, learning problems or being oppositional.

Distraction: If a child is busy thinking that if she doesn't turn the pen cap and count to four the right way then her mom is going to get sick, she's not going to be paying attention in class. And if her teacher calls on her to answer a question, her distraction might look like ADHD, but it isn't.

Slowness on exams, papers and tasks: Sometimes when kids take a long time, they're struggling with the perfectionism of needing to do things the right way. This could look like learning problems, or inattention, but it isn't.

Avoidance: Teachers might see a child who doesn't want to sit on the floor, or pick things up that touched the floor, or get his hands dirty in art class. He may avoid a lot of playground activities - kids with germ fears will view the playground the way some adults view the subway: it's gross. Why touch anything there?

Tapping and touching symmetrically: If a child sits down at her desk and she accidentally kicks the chair of the kid next to her with her right foot, she's going to have to then kick it with her left foot. That might look like somebody who's being oppositional, or somebody who's got too much energy, but actually it's OCD.

Complaints of anxiety and fatigue: There's one interesting theory that kids with OCD are smarter than other kids. And if you consider how much thinking they're doing, they're really using their brain more frequently than a lot of other kids are. But when that's coupled with a lot of anxiety, you can have a lot of fatigue. So it's common for kids with OCD to want to come home and take a nap after school.

How to Help Students With OCD

For children struggling with OCD, functioning in school can be complicated and very difficult. Here are some things you can do to help them, and the class as a whole, focus on learning:

Seating arrangement: If the school has noisy hallways, you might not want to have a child with OCD sit by the door. You might have her sit in the front, where she's less able to hear the noise and can stay more focused on her work. On the other hand, a child who has very observable symptoms, and doesn't want other kids to see her fidgeting with her hands, rocking or getting up a lot, might be better off closer to the door, toward the back of the room.

Extended time for tests and papers: If writing is a problem for a child who needs to find the perfect way to say something, he's going to need more time to finish those essay questions or papers.

Laptops for writing: If writing and rewriting/erasing is really problematic for a child, consider letting her use a laptop for taking notes, and having all assignments be typed instead of handwritten.

Private testing rooms: Research is quite clear that kids with OCD do better, are less overwhelmed and are more in control of their thoughts and their reactions if they're in a quiet place away from the other kids.

Skip reading out loud: Kids who feel they need to read perfectly may have to go back and reread sentences or whole paragraphs over and over to make sure they've got them right. So reading becomes a very laborious task, and reading in front of the class can become a nightmare. So if we know doing this is a problem for children, we can spare them.

Books on tape: If kids get so hung up reading that it takes forever, listening to the books can be a solution.

Break homework into chunks: If looking at a whole page of math makes kids feel overwhelmed and anxious - think of the potential for mistakes! - the problems can be broken up over four pages. It helps kids stay focused on doing the problems instead of worrying.

How to Minimize Behavioral Problems

Plan an escape route: Try working out a communication system so that if the student feels symptoms coming on, she can signal to you and leave the classroom, or go to a protected place in the classroom, without interrupting the class. It can prevent an embarrassing and disruptive blowup of symptoms in the classroom, and the other kids picking on or bullying her about it.

Be aware of triggering events: It's very important for teachers to know what kind of things might trigger the symptoms. Fatigue is a huge piece of OCD, and it can be exacerbated by medication. So it's important to know that if a child is drowsy in class, and maybe he's putting his head down, it's not because he's being oppositional or disrespectful, but because he's overwhelmed with fatigue.

Advance notice: Irritability and frustration are two of the longer-lasting things that kids with OCD are feeling on a daily basis. Changes in schedule can be very disruptive for a child with OCD, so it can be helpful for teachers to give advance notice of things. Kids who know what to expect are less likely to be thrown by the change.

Children with OCD are often teased and bullied because of their symptoms. Kids feel very uncomfortable about their rituals, knowing that they're being watched. It can be helpful to educate the whole class about what's going on, especially if a child is going to be in the same school for a number of years, and it can inspire a surprising amount of support from other children.

Peer understanding program: A peer understanding program includes a presentation in the classroom that explains (with the child participating) what OCD is. The child might say, "Listen, I have OCD. It's an anxiety disorder. It makes me think that my hands are dirty and I have to wash my hands a lot, so if you see me getting up and going to the sink to wash my hands, that's why." Psychologists can role-play with the teacher and child ahead of time, to anticipate questions his classmates might ask, and how to answer them.

A buddy system: A buddy is like a peer coach who sits next to the child and prompts him to keep up with note taking and staying on task. It can be great for the buddy, to foster a sense of confidence and pride and to be able to help someone in need, and great for fostering friendship.

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Lo sentimos, la página que usted busca no se ha podido encontrar. Puede intentar su búsqueda de nuevo o visitar la lista de temas populares. Children who have obsessive-compulsive disorder (OCD) are plagued with unwanted thoughts, images or impulses that are difficult to suppress, causing them great stress and worry.

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Working with students with Emotional Disturbance

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Working with students with Emotional Disturbance

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School counselors working with student anxiety

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School counselors working with student anxiety

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"My heart is pounding. I feel like I can't breathe. My stomachs hurts. I don't want to be here at school. I know I shouldn't be worried about it, but I

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Cornacchio, D., Chou, T., Sachs, H., Pincus, D. comer, J. (2015). Clinical consequences of the revised DSM-5 definition of agoraphobia in treatment seeking anxious youth. Depression and Anxiety, 32, 502-508. https://pubmed.ncbi.nlm.nih.gov/25845579/

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Cornacchio, D., Chou, T., Sachs, H., Pincus, D. comer, J. (2015). Clinical consequences of the revised DSM-5 definition of agoraphobia in treatment seeking anxious youth. Depression and Anxiety, 32, 502-508. https://pubmed.ncbi.nlm.nih.gov/25845579/

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When worrying gets in the way of a child's functioning, parents need to get help rather than arranging the child's life to avoid the occasions of anxiety.

Credit... Getty Images

By

Anxiety disorders, the most common mental health problems in children and adolescents, often go untreated while children suffer, even though there are effective treatments available, according to a new report on anxiety in children and adolescents from the Child Mind Institute in New York. Anxiety may be missed because it doesn't necessarily declare itself with attention-getting disruptive behaviors; in fact, symptoms may keep some children quiet and inhibited, though in other children, alternatively, anxiety may be misunderstood as oppositional behavior.

Adults may also assume that anxiety in a child is just a phase to be outgrown. A certain amount of anxiety is a normal aspect of development for young children - consider separation anxiety, for example - and it can even be protective, since children need to learn to keep themselves safe and anticipate certain kinds of dangers. But when worrying or avoiding possible threats gets in the way of a child's functioning or a child's enjoyment, it should be a signal to parents that help is needed, not just watching and waiting, not arranging the child's life to avoid the occasions of anxiety.

Kathleen Merikangas, the senior investigator and chief of the Genetic Epidemiology Research Branch at the National Institute of Mental Health, said, "To me, anxiety is one of the most underrecognized or under-treated conditions of childhood and adolescence." These children can get missed, she said, because they may seem to be functioning well; many don't have the kinds of developmental problems or attention issues that draw attention in school, though they may be suffering.

Consider the child whose anxiety about speaking in public gets in the way of participating in class. The child may be silent out of a fear of being laughed at or otherwise rejected, Dr. Merikangas said, but to the teacher, it may look like the child is just not interested. Environmental modifications can really help these children thrive in school, she said; for example, working in small groups with children they know.

The new report, released in September, summarizes the evidence that early temperament in children predicts their later behavior patterns around anxiety; toddlers who show what are called "behaviorally inhibited" behaviors, which parents are likely to perceive as extreme shyness, or anxiety around new people, are more likely to develop social anxiety later on. That doesn't mean that shyness is pathological (as with all varieties of temperament, there's a wide range of function), but it does suggest how important it is to help a child with this temperament who develops difficulties.

The tendency toward anxiety - and toward some specific forms of anxiety, like phobias - may persist throughout childhood and adolescence and into adulthood. And anxiety is closely tied to depression, Dr. Merikangas said. Although there have been reports that anxiety rates among American teenagers have soared, she cited evidence that the international rates of the underlying disorders had stayed consistent from 1998 to 2013; there is no global "epidemic" of clinical anxiety disorders, she said.

But with rates of suicide and suicidal ideation on the rise, it's particularly important to provide information to schools and to parents about recognizing anxiety and getting children help.

Dr. Harold Koplewicz, the president of the Child Mind Institute, said that when anxiety disorders in children are left untreated, anxiety can inhibit their lives, making standard daily activities difficult, from attending school to sleeping in their own beds, and lead to many extra visits to the school nurse or the pediatrician.

But beyond that, he said, "people underestimate that this is a gateway disorder." If children don't get help with these disorders, they may be at risk to develop other mental health problems; the child with severe separation anxiety may develop panic disorder, he said; the child with untreated general anxiety may be at greater risk for depression.

Dr. Merikangas was a co-investigator on a national study of mental disorders in adolescents, which has shown both that anxiety disorders were the most common mental health problems in adolescents in the United States, and also the problems that showed up earliest in those children's lives - the mean age of onset for anxiety disorders was 6. But many adolescents had never received treatment. That makes it essential to get the word out, Dr. Merikangas said, that anxiety is "one of the most treatable symptoms and syndromes, we can really change their lives with minimal intervention."

"All these disorders are remarkably treatable," Dr. Koplewicz said. There are highly effective behavioral and psychosocial therapies, including cognitive behavioral therapies, to help children cope with the demands of daily life. For children who don't respond to psychosocial therapies, he said, medications can be added.

But perhaps because anxiety is a normal response, parents often believe that even severe and disabling anxiety symptoms are just a phase, and on average, there is a two-year lag between the time children develop anxiety and the time they get help. "It's bad for these children's brains," he said. "Having your brain's thermostat miss-set is not good for your brain."

"Anxiety can manifest itself along a continuum," said Rachel Busman, the senior director of the anxiety disorders center at the Child Mind Institute. The report shows that there is some overlap with physical illnesses, such as chronic headaches or stomach aches, often coordinated with school. "That could be a kid's way of saying, 'I'm anxious,'" she said.

And when a child who is having a lot of difficulty with separation gets into the classroom, Dr. Busman said, that child may start throwing things, or running and hiding, and that "bad behavior" may represent the fight or flight response of anxiety. "We've also seen kids who have intense social anxiety and their way of managing it is to be class clown," she said.

Treating children with anxiety always means working with their parents. Jerry Bubrick, senior clinical psychologist at the anxiety disorders center of the Child Mind Institute, said that when children are little, it's normal for parents to operate in "fix-it mode," blocking the staircase so a toddler doesn't tumble down, averting problems before they happen.

As children get older, parents normally pull back, helping children find solutions of their own. "But anxious parents of anxious children remain in fix-it mode," he said, helping their children avoid the situations that make them anxious. Therapy involves exposing children to those situations and helping them develop strategies to manage them; with treatment, Dr. Bubrick said, parents can "let the child experience the anxiety and learn to tolerate and overcome it on their own."

"If you see things you're not sure about, talk to the preschool, talk to the pediatrician, be open to the idea that maybe there is anxiety," even in a young child, Dr. Busman said. Separation anxiety can be a problem even in children who are able to go to school, she said. Parents should pay attention if a child can't be left with a babysitter, a child can't sleep alone at home."These are the kids, they go into the bathroom, and they're like, are you still there?" she said. "We do see really young anxious children."

"If your child is suffering distress and dysfunction, reach out to your pediatrician," Dr. Koplewicz said. When you get to a mental health professional, "make sure you ask the right questions," he said, including asking whether that person has specific experience with treating anxiety and how long the treatment is expected to take.

"You want a professional who understands what they're doing and can explain to you what they're doing."

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How to Help a Child With an Anxiety Disorder

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When worrying gets in the way of a child's functioning, parents need to get help rather than arranging the child's life to avoid the occasions of anxiety. By Anxiety disorders, the most common mental health problems in children and adolescents, often go untreated while children suffer, even though there are effective treatments available, according to a new report on anxiety in children and adolescents from the Child Mind Institute in New York.

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Inconsistent Academic Results Can be a Sign of Mental Health Issues

These disorders can also lead to inconsistent academic results. For example, a student may produce incredible work one day and barely be able to complete a single task the next. This unpredictable behavior is a prevalent sign that anxiety or depression might be present. The inconsistency of these disorders can leave students feeling frustrated and teachers confused and unsure how to approach the situation.

When students are depressed or are dealing with anxiety, they are more likely to disengage in the classroom.

This can cause them to participate in behaviors that will allow them to avoid certain events and situations. For example, missing class or going to the nurse during a quiz or presentation are a few ways students may demonstrate an anxiety disorder.

Teachers have to be prepared and know which signs to look for so that they can determine what is really going on with the student and how they can best help them.

Missing Class Can be a Sign of Anxiety

These disorders can also lead to school refusal, or school phobia. This is when a student's anxiety or depression is so severe that they begin avoiding going to school at all. This can begin with missing class, going home early and staying home, but eventually can lead to school drop out. The Centre for Emotional Health at Macquarie University states that 49% of adults with anxiety reported leaving school early and 24% claimed that anxiety was the primary reason for them leaving.

The negative impact anxiety and depression have on students' academic performance doesn't just hurt them and their families, but it has consequences for the economy and society as a whole because they are not receiving a proper education.

Risks That Can't be Ignored

When anxiety and depression are not identified and properly addressed there are long-term risks for students.

A student dealing with one of these disorders can experience negative effects on their attention, interpretation, concentration, memory, social interaction and physical health.

All of these factors play a key role in each student's academic success and achievement. A child who has anxiety is more likely to focus their attention on things that they perceive to be a possible threat rather than focusing on what is important, like learning in the classroom. Individuals will also interpret everyday situations as dangerous or threatening and will often assume the worst case scenario.

When someone is experiencing anxiety or depression the majority of their mental capacity is used to create and process worrisome thoughts. This can make it extremely difficult to focus on positive thoughts and can be very exhausting for the student, which detracts from their learning abilities.

Not only do these disorders impact memory, which makes it hard for students to recall information, but they can also have negative effects on how students engage in social situations. Often, students with anxiety or depression will avoid interactions with their peers and will perceive neutral situations as threats. This, in turn, makes others uncomfortable and results in the student feeling lonely, outcast and increases anxiety and depression.

Physical symptoms like headache, fatigue, nausea and unexplained illness are also risks of untreated anxiety and depression. Children with these disorders have a higher resting heart rate, higher blood pressure, higher cortisol levels and they carry more tension in the body. These physical effects often lead to missed school days causing the child to fall behind.

Dealing with undiagnosed depression or anxiety can result in students feeling like they are constantly missing out on opportunities and this can lead to substance abuse, conduct problems, further mental health problems and even suicide.

Currently, suicide is the second leading cause of death among college students. Heather Morgan, a crisis line manager for Didi Hirsch Mental Health Services Suicide Prevention Center says, "We receive calls from college students daily. Since people go through different traumatic events in life; calls, texts and chats can range from relationship issues, LGBTQI questions or concerns, financial, and family issues or concerns - to name a few."

The negative impact of anxiety and depression on student's academic progress and overall well-being is very clear. Early anxiety disorders typically predict adult anxiety disorders making it crucial to address them early on. 85% of depressed adolescents have a history of having anxiety as a child. If these issues can be identified early on while the child is in school there is a better chance for treatment and preventative care so that the above consequences can be avoided.
Teachers and Schools Need to be Prepared
Under the Individuals with Disabilities Education Act (IDEA), parents have the right to request appropriate accommodations related to their child's diagnosis. Teachers and school staff need to be able to respond effectively and know which accommodations to provide for each student.
Mental health training is crucial in schools, especially for teachers, who are interacting with students on a daily basis and have many opportunities to observe behavior and reach out.
A mental health training program will prepare teachers and staff to look for discreet signs that may indicate disorders like anxiety. These signs include increased inflexibility, over-reactivity, emotional intensity, impulsivity, acting out or escaping to avoid a situation. Very often a student may go to the nurse during a quiz or get kicked out of class on purpose. Teachers may interpret the child as simply being a troublemaker or slacking off, when in reality, they are feeling intense anxiety and are trying to protect themselves.

There's a reason anxiety and depression are referred to as invisible diseases. It can be very difficult to identify these disorders in students unless teachers have a deep understanding of them and know exactly what to look for. Training is necessary because the best way to improve these conditions are to address them as soon as possible.

Isabel, a school superintendent in California says, "In most schools mental health certification is reserved for a social worker or guidance counselor. Yet 99.9% of student contact time everyday is with a teacher, bus driver or coach. Our number one priority should be to train and equip our front line staff to deal with this crisis."

Teachers and classroom staff are on the front lines of helping students seek proper treatment and receive an education in a safe, comfortable environment. When school staff and teachers are properly trained they are able to effectively address anxiety and depression among their students and create a better learning environment that will produce higher academic outcomes.
Student Mental Health Training and Certification
IBCCES and their board of experts , including international leaders in the educational field, Tier 1 University researchers, master educators, and clinical professionals, have designed a Student Mental Health Specialist (SMHS) training and Student Mental Health Certificate (SMHC) certification . 81% of teens with anxiety responded positively to teacher intervention and 71% of students with depression had higher test results after teacher engagement.

The purpose of the SMHS and SMHC training and certification is to prepare teachers and other school staff to provide support for students in the classroom while monitoring changes in student behavior and understanding common disorders or mental health concerns. The IBCCES program is unique because it combines training with independently verifiable certification, providing schools with the resources they need to support students and parents to enhance learning opportunities and the overall school atmosphere.

Benefits of the SMHS and SMHC program include:

Access to relevant strategies that can be implemented immediately

Best practices and latest research in anxiety and mental health disorders

Confidence to handle stressful situations and approach students with useful tools

Ability to improve learning for students and produce better academic results

Credibility and recognition for the staff and school

Ability to create a sense of security in the classroom.

Take the First Step
The SMHS and SMHC program consists of a convenient six step process that can be completed online.

There is no reason why teachers and school staff have to continue feeling unprepared and student anxiety and depression has to continue going unnoticed and unaddressed.

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Impact of Anxiety and Depression on Student Academic Progress

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These disorders can also lead to inconsistent academic results. For example, a student may produce incredible work one day and barely be able to complete a single task the next. This unpredictable behavior is a prevalent sign that anxiety or depression might be present.

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Does your child go through extreme changes in mood and behavior? Does your child get much more excited or much more irritable than other kids? Do you notice that your child goes through cycles of extreme highs and lows more often than other children? Do these mood changes affect how your child acts at school or at home?

Some children and teens with these symptoms may have bipolar disorder, a brain disorder that causes unusual shifts in mood, energy, activity levels, and day-to-day functioning. With treatment, children and teens with bipolar disorder can get better over time.

What is bipolar disorder?

Bipolar disorder is a mental disorder that causes people to experience noticeable, sometimes extreme, changes in mood and behavior. Sometimes children with bipolar disorder feel very happy or "up" and are much more energetic and active than usual. This is called a manic episode. Sometimes children with bipolar disorder feel very sad or "down" and are much less active than usual. This is called a depressive episode.

Bipolar disorder, which used to be called manic-depressive illness or manic depression, is not the same as the normal ups and downs every child goes through. The mood changes in bipolar disorder are more extreme, often unprovoked, and accompanied by changes in sleep, energy level, and the ability to think clearly. Bipolar symptoms can make it hard for young people to perform well in school or to get along with friends and family members. Some children and teens with bipolar disorder may try to hurt themselves or attempt suicide.

Most people are diagnosed with bipolar disorder in adolescence or adulthood, but the symptoms can appear earlier in childhood. Bipolar disorder is often episodic, but it usually lasts a lifetime.

Signs and symptoms of bipolar disorder may overlap with symptoms of other disorders that are common in young people, such as attention-deficit/hyperactivity disorder (ADHD), conduct problems, major depression, and anxiety disorders. Diagnosing bipolar disorder can be complicated and requires a careful and thorough evaluation by a trained, experienced mental health professional.

With treatment, children and teens with bipolar disorder can manage their symptoms and lead successful lives.

What causes bipolar disorder?

The exact causes of bipolar disorder are unknown, but several factors may contribute to the illness.

For example, researchers are beginning to uncover genetic mechanisms that are linked to bipolar disorder and other mental disorders. Research shows that people's chance of having bipolar disorder is higher if they have a close family member with the illness, which may be because they have the same genetic variations. However, just because one family member has bipolar disorder, it does not mean that other members of the family will have it. Many genes are involved in the disorder, and no single gene causes it.

Research also suggests that adversity, trauma, and stressful life events may increase the chances of developing bipolar disorder in people with a genetic risk of having the illness.

Some research studies have found differences in brain structure and function between people who have bipolar disorder and those who do not. Researchers are studying the disorder to learn more about its causes and effective treatments.

What are the symptoms of bipolar disorder?

Mood episodes in bipolar disorder include intense emotions along with significant changes in sleep habits, activity levels, thoughts, or behaviors. A person with bipolar disorder may have manic episodes, depressive episodes, or "mixed" episodes. A mixed episode has both manic and depressive symptoms. These mood episodes cause symptoms that often last for several days or weeks. During an episode, the symptoms last every day for most of the day.

These mood and activity changes are very different from the child's usual behavior and from the behavior of healthy children and teens.

Children and teens having a manic episode may:

Show intense happiness or silliness for long periods of time.

Have a very short temper or seem extremely irritable.

Talk fast about a lot of different things.

Have trouble sleeping but not feel tired.

Have trouble staying focused, and experience racing thoughts.

Seem overly interested or involved in pleasurable but risky activities.

Do risky or reckless things that show poor judgment.

Children and teens having a depressive episode may:

Feel frequent and unprovoked sadness.

Show increased irritability, anger, or hostility.

Complain a lot about pain, such as stomachaches and headaches.

Have a noticeable increase in amount of sleep.

Have difficulty concentrating.

Feel hopeless and worthless.

Have difficulty communicating or maintaining relationships.

Eat too much or too little.

Have little energy and no interest in activities they usually enjoy.

Think about death, or have thoughts of suicide.

Can children and teens with bipolar disorder have other problems?

Young people with bipolar disorder can have several problems at the same time. These include:

Misuse of alcohol and drugs. Young people with bipolar disorder are at risk of misusing alcohol or drugs.

Attention-deficit/hyperactivity disorder (ADHD). Children and teens who have both bipolar disorder and ADHD may have trouble staying focused.

Anxiety disorders. Children and teens with bipolar disorder also may have an anxiety disorder.

Sometimes extreme behaviors go along with mood episodes. During manic episodes, young people with bipolar disorder may take extreme risks that they wouldn't usually take or that could cause them harm or injury. During depressive episodes, some young people with bipolar disorder may think about running away from home or have thoughts of suicide.

If your child shows signs of suicidal thinking, take these signs seriously and call your child's health care provider.
If you think your child is in crisis and needs immediate help, call 911. You also can call the National Suicide Prevention Lifeline (Lifeline) at 1‑800‑273‑TALK (8255), or text the Crisis Text Line (text HELLO to 741741). The deaf and hard of hearing can contact the Lifeline via TTY at 1-800-799-4889. These services are confidential, free, and available 24/7.

How is bipolar disorder diagnosed?

A health care provider will ask questions about your child's mood, sleeping patterns, energy levels, and behavior. There are no blood tests or brain scans that can diagnose bipolar disorder. However, the health care provider may use tests to see if something other than bipolar disorder is causing your child's symptoms. Sometimes health care providers need to know about medical conditions in the family, such as depression or substance use.

Other disorders have symptoms like those of bipolar disorder, including ADHD, disruptive mood regulation disorder, oppositional defiant disorder, conduct disorder, and anxiety disorders. It also can be challenging to distinguish bipolar disorder from depression that occurs without mania, which is referred to as "major depression." A health care provider who specializes in working with children and teens can make a careful and complete evaluation of your child's symptoms to provide the right diagnosis.

How is bipolar disorder treated?

Children and teens can work with their health care provider to develop a treatment plan that will help them manage their symptoms and improve their quality of life. It is important to follow the treatment plan, even when your child is not currently experiencing a mood episode. Steady, dependable treatment works better than treatment that starts and stops.

Treatment options include:

Medication. Several types of medication can help treat symptoms of bipolar disorder. Children respond to medications in different ways, so the right type of medication depends on the child. This means children may need to try different types of medication to see which one works best for them. Some children may need more than one type of medication because their symptoms are complex. Children should take the fewest number of medications and the smallest doses possible to help their symptoms. A good way to remember this is "start low, go slow." Medications can cause side effects. Always tell your child's health care provider about any problems with side effects. Do not stop giving your child medication without speaking to a health care provider. Stopping medication suddenly can be dangerous and can make bipolar symptoms worse.

Psychosocial Therapy. Different kinds of psychosocial therapy can help children and their families manage the symptoms of bipolar disorder. Therapies that are based on scientific research-including cognitive behavioral approaches and family-focused therapy-can provide support, education, and guidance to youth and their families. These therapies teach skills that can help people manage bipolar disorder, including skills for maintaining routines, enhancing emotion regulation, and improving social interactions.

What can children and teens expect from treatment?

With treatment, children and teens with bipolar disorder can get better over time. Treatment is more effective when health care providers, parents, and young people work together.

Sometimes a child's symptoms may change, or disappear and then come back. When this happens, your child's health care provider may recommend changes to the treatment plan. Treatment can take time, but sticking with the treatment plan can help young people manage their symptoms and reduce the likelihood of future episodes.

Your child's health care provider may recommend keeping a daily life chart or mood chart to track your child's moods, behaviors, and sleep patterns. This may make it easier to track the illness and see whether treatment is working.

How can I help my child or teen?

Help begins with the right diagnosis and treatment. Talk to your family health care provider about any symptoms you notice.

If your child has bipolar disorder, here are some basic things you can do:

Be patient.

Encourage your child to talk, and listen to your child carefully.

Pay attention to your child's moods, and be alert to any major changes.

Understand triggers, and learn strategies for managing intense emotions and irritability.

Help your child have fun.

Remember that treatment takes time: sticking with the treatment plan can help your child get better and stay better.

Help your child understand that treatment can make life better.

How does bipolar disorder affect caregivers and families?

Caring for a child or teenager with bipolar disorder can be stressful for parents and families. Coping with a child's mood episodes and other problems-such as short tempers and risky behaviors-can challenge any caregiver.

It is important that caregivers take care of themselves, too. Find someone you can talk to or consult your health care provider about support groups. Finding support and strategies for managing stress can help you and your child.

Where do I go for help?

If you're not sure where to get help, your doctor, pediatrician, or other family health care provider is a good place to start. A health care provider can refer you to a qualified mental health professional, such as a psychiatrist or psychologist, who has experience treating bipolar disorder and can evaluate your child's symptoms.

You can learn more about getting help and finding a health care provider on the National Institute of Mental Health website. Hospital health care providers can help in an emergency. The Substance Abuse and Mental Health Services Administration (SAMHSA) has an online tool to help you find mental health services in your area.

I know someone who is in crisis. What do I do?

If you know someone who might be thinking about hurting themselves or someone else, get help quickly.

Do not leave the person alone.

Call 911 or go to the nearest hospital emergency room.

Call the toll-free National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or the toll-free TTY number at 1-800-799-4TTY (4889). You also can text the Crisis Text Line (text HELLO to 741741) or go to the National Suicide Prevention Lifeline website.

What should I know about clinical trials?

Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Researchers at NIMH and around the country conduct clinical trials with patients and healthy volunteers. Talk to your health care provider about clinical trials, their benefits and risks, and whether one is right for you. For more information, visit the NIMH Clinical Trials webpage.

Reprints

This publication is in the public domain and may be reproduced or copied without permission from NIMH. Citation of NIMH as a source is appreciated. To learn more about using NIMH publications, please contact the NIMH Information Resource Center at 1-866‑615‑6464, email nimhinfo@nih.gov, or refer to our reprint guidelines.

For More Information

MedlinePlus (National Library of Medicine) ( En español)

ClinicalTrials.gov ( En español)

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication No. 20-MH-8081
Revised 2020

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Does your child go through extreme changes in mood and behavior? Does your child get much more excited or much more irritable than other kids? Do you notice that your child goes through cycles of extreme highs and lows more often than other children?

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Helping students in your class or in counseling. 

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Helping students in your class or in counseling. 

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by Stacia Levy 13,333 views

It's no secret that many ESL students are troubled individuals, having experienced trauma in their home countries. In addition, the immigration process itself is often a source of trauma as students and their families try, with varying degrees of success, to adjust to their new culture. These anxieties often get played out in an ESL classroom, where troubled students might come into contact with other similarly troubled students.

What are Some Dysfunctional ESL Student Types?

Dysfunctional behavior and ways of relating to one another are, in my experience, universal, with negative patterns occurring across cultures and genders rather than being associated with any specific one. Some of the types you may see are the following:

1. Miss Codependent

"Dependent" seems to be the operant part of the term, with the student viewing the teacher as a parent figure. This isn't necessarily bad, to an extent. A student last term, for example, told me she saw me as a " second mom," which I found flattering, not a cause for concern, for the student, very new to U.S. culture, simply accepted-and then applied-- some pointers for getting along in an American college. It's when students solicit help but then ignore it yet keep coming back for more that the problem arises. This may be called "codependent" behavior, when both parties are locked in a dysfunctional pattern of continually helping and requesting help. A teacher's job is in fact to help-but ultimately to help students toward independence. It is tricky to balance helping yet not helping too much, but it can be done by limiting the amount of help given to the same student. If he always comes to class unprepared, for example, the teacher should stop lending out paper, pens, dictionaries, the text, etc., which will teach the student to bring his own materials.

2. Mr. Passive Aggressive

Mr. Passive Aggressive goes through the course syllabus thoroughly, looking for loopholes to wiggle through. If the syllabus says students may be absent "up to three times," he is absent two times then asks if "up to three" includes a third time or really means only two. He sleeps in class. He turns in papers with extra-large font, a title page, pictures, and an extensive bibliography to get to the required page count.

Since Mr. Passive Aggressive seems to thrive on exploiting the ambiguous, make materials as clear as possible: "A thousand words means a thousand words, Mr. Passive Aggressive. No more nor less." You may also call the passive aggressive behavior what it is: "Sleeping in class seems rude. Can you explain to me why you do it?" Because direct questions bother Mr. Passive Aggressive, he will likely stop the behavior.

3. Ms. Antisocial

The gloves are off with Ms. Antisocial. There is nothing passive about her aggressive: she is loud and belligerent in challenging the teacher and her peers. Sometimes other students are frightened of and avoid working with her groups, which is fine with her-she'd rather sit alone and glower or carry on angry cell phone conversations, anyway. Sometimes the antisocial behavior carries over into course writing-essays or journals, in which the student recounts aggressive encounters with others.

Dealing with the. anti-social student requires care. Once, with a student whose journals were his venting of anger with his girlfriend, his best friend, his mother, etc., I scrawled a note that he might benefit from therapy and didn't think I was at all out of line. In other cases, I've pulled aggressive students aside and simply asked for more cooperation in class. Usually students will comply-never becoming the most popular classmate, but at least getting along with their peers well enough for the duration of the course.

4. Mr. Oh-So-Shy

You know this type of shrinking violet. Mr. Oh-So-Shy won't open his mouth in class and has to be almost dragged into group work. His eyes are usually on his book or an electronic device.

Gentle insistence with the shy type is most effective: he must put away his electronics and books, join a group, and participate. Since Mr. Oh-So-Shy is not usually antisocial, just shy, finding a classmate he can relate to also helps him relax and participate.

General Methods to Address the Dysfunctional Types in Your Class:

The good news is almost never do all of these dysfunctional types turn up in one class. The bad news is it can take only one to ruin a class. How do you keep him or her from doing that?

1. Set the Tone

The teacher sets the tone that she wants from the beginning through the course syllabus and on how she treats the students: friendly yet professional.

2. Establish Norms

Group norms, the acceptable and unacceptable behavior for the class, can be established in a list. If you find text-messaging unacceptable during group work, state so in the list. Have students add their own norms for the class or for their groups.

3. Keep your Cool

Keep your cool with students, and don't lose your temper even with the most exasperating student. This relates to establishing the norms-if it is an expectation that students always treat each other with kindness and respect, the teacher is responsible for modeling this value.

4. --Until You Lose Your Cool

Sometimes the teacher "losing it" is an effective technique. The trick is that this is really a strategy, and the teacher who appears to have lost his temper is still in control of the situation. The point of "blowing your cool" with students is to reaffirm "this is not how we act" in an extreme violation of the group norms.

5. Regroup, Reaffirm the Norm

After your brief tirade, or mild scolding, or earnest discussion, however you choose to handle the departure from the norm, be sure to reaffirm the norms. For example, a high school teacher I know who found a group of his students had defaced the halls with graffiti stalked into class and treated the abashed students to a stern lecture about how disappointed he was, that they were nothing more than gang members in the making; the instigators would be smoked out and the authority notified, etc. His ending comments, however, returned to the group norms: "This is not how civilized people act, and it is not, specifically, how we act at this school." The point of such a tirade is ultimately not to intimidate the students but rather to draw a stark line between what is acceptable and unacceptable behavior and is effective only when the teacher is by contrast usually calm.

Everyone believes my classes must be very interesting, and they are-"interesting" being subject to interpretation, of course.

ESL classes attract more than their share of troubled students who should be treated with care while being gently guided to the behavior expected in an American university.
Who are your troubled students? How do you treat them?

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Therapy for the Dysfunctional Classroom: Advising and Teaching Your Troubled Students

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by Stacia Levy 13,333 views It's no secret that many ESL students are troubled individuals, having experienced trauma in their home countries. In addition, the immigration process itself is often a source of trauma as students and their families try, with varying degrees of success, to adjust to their new culture.

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Great movie on students struggling with Anorexia Nervosa. 

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Great movie on students struggling with Anorexia Nervosa. 